Proposal Form

A

Fixed Site Pollution Liability

NEW BUSINESS AU | Investment Managers | Policy Wording | Feb 2019

PROPOSAL FORM Level 3 Equus Building PO Box 5759 T: +61 8 6188 9500 libertyspecialtymarkets.com.au580 Hay Street St Georges Terrace E: [email protected] Perth WA 6000 Australia Perth WA 6831 Australia W: libertyspecialtymarkets.com.au

Liberty Specialty markets, a trading name of Liberty Mutual Insurance Company (ABN 61 086 083 605) Incorporated in , USA (the liability of members is limited). Proposal Form p.1 of 10

IMPORTANT NOTICE The information provided in this proposal will form the basis of any contract of insurance entered into. Please read the following notices carefully and ensure you answer all questions in full and read and sign the Declaration at the end.

FOR CLAIMS MADE INSURANCE This is a proposal for a ‘Claims Made’ policy of insurance. This means that the policy covers you for any claims made against you and notified to the insurer during the policy period. The policy does not provide cover in relation to:

• pollution conditions that occurred prior to the retroactive date (if one is specified) in the policy; • any claim made, threatened or intimated against you prior to the commencement of the policy period; • any claim or fact that might give rise to a claim, reported or which can be reported to an insurer under any insurance policy entered into before the commencement of the policy period; • any claim or fact that might give rise to a claim, noted in this proposal or any previous proposal; • any claim arising out of any fact you are aware of before the commencement of the policy period; • any claim made against you after the expiry of the policy period.

However, the effect of Section 40(3) of the Insurance Contracts Act 1984 (Cth) is that where you become aware, and notify us in writing as soon as is reasonably practicable after first becoming aware but within the policy period, of any facts which might give rise to a claim against you, any claim which does arise out of such facts shall be deemed to have been made during the policy period, notwithstanding that the claim was made against you after the expiry of the policy period.

YOUR DUTY OF DISCLOSURE Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984 (Cth), to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer's decision whether to accept the risk of the insurance and, if so, on what terms. This includes but is not limited to every fact and matter that you know, or could reasonably be expected to know that might give rise to a claim against you. This may also include information which is additional to the questions asked in this proposal form. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. This means that prior to renewal or any policy variations, as well as advising of new information, you also need to advise the insurer of any changes to the facts previously notified. Your duty however does not require disclosure of matter: • that diminishes the risk to be undertaken by the insurer; • that is of common knowledge; • that your insurer knows or, in the ordinary course of its business, ought to know; • as to which compliance with your duty is waived by the insurer.

Liberty means Liberty Mutual Insurance Company, Australia Branch (ABN 61 086 083 605) trading as Liberty Specialty Markets incorporated in Massachusetts, USA (the liability of members is limited) Proposal Form p.2 of 10

NON DISCLOSURE If you fail to comply with your duty of disclosure or make a material misrepresentation to us, the insurer may be entitled to reduce their liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning and therefore decline to pay any claim. This means that your policy would be deemed to have never existed and no claims would be payable.

PRIVACY NOTICE Liberty Specialty Markets is a trading name of Liberty Mutual Insurance Company, Australia Branch (ABN 61 086 083 605) incorporated in Massachusetts, USA (the liability of members is limited) (Liberty). It is a member of -based Liberty Mutual Group. Liberty Australia’s head office contact details are: Address: Locked Bag 18, Royal Exchange NSW 1225, Australia Phone: +61 2 8298 5800 Liberty is bound by the Privacy Act 1988 (Cth) and its associated Australian Privacy Principles when it collects and handles your personal information. Liberty collects personal information, including from insurance brokers, in order to provide its services and products, manage claims and for purposes ancillary to its business. Liberty passes it to third parties involved in this process such as Liberty’s related companies, reinsurers, agents, loss adjusters and other service providers. We may store your information with third party cloud or other types of networked or electronic storage providers. Third parties may be located locally or overseas in the United States, Canada, , , and . Your information may be transferred to countries without comparable privacy laws if it is reasonably necessary to provide you with the products or services you seek from Liberty. If you do not provide the personal information Liberty or other relevant third parties require to offer you specific products or services, Liberty may not be able to provide the appropriate type or level of service. If you wish to gain access to or correct your personal information, make a privacy complaint, or if you have any query about how Liberty collects or handles your personal information please write to Liberty’s Privacy Officer at the address above or by emailing: [email protected]. To obtain a copy of Liberty’s Privacy Policy go to Liberty’s website (www.libertyspecialtymarkets.com.au) or request a copy from Liberty’s Privacy Officer. When you give Liberty personal or sensitive information about other individuals, Liberty relies on you to provide its Privacy Notice to them. If you have not done this, you must tell Liberty before you provide the relevant data.

Proposal Form p.3 of 10

INSTRUCTIONS

Important: Please answer all questions fully. If any section does not apply, please indicate with N/A. All questions will be deemed to be answered in respect of all entities & persons to be insured under this policy. If the space provided is insufficient please include attachments on your company letterhead.

This application must be signed and dated by an owner, principal or other duly authorised person. Please submit the following with this application:

Environmental Audit Reports for each location requiring coverage (if available) Information on any previous environmental coverage and environmental loss experience Environmental site management plan

APPLICATION FOR FIXED SITE POLLUTION LIABILITY

THE INSURED

1. Named Insured

2. Postal Address

3. Email Website Address 4. List of Subsidiaries

5. Period of Insurance From: at 4pm Local Standard Time To: at 4pm Local Standard Time

TURNOVER

6. Fiscal Year From:

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To: Current Fiscal Year $ Estimated for next Fiscal Year $

COMPANY OPERATIONS

7. Operations of the Named Insured

COVERED LOCATIONS

8. Please complete Appendix A with details of locations that are required to be covered by this policy

COVERAGE DETAILS

9. Coverage Limit $ 10. Deductible $

If you require further options, please discuss with your broker

11. Please select required coverage: a. Clean-up Costs Resulting from New Pollution Conditions b. Clean-up Costs Resulting from Pre-Existing Pollution Conditions c. Bodily Injury and Property Damage Resulting from Pollution Conditions d. Bodily Injury, Property Damage and Clean-up Costs Resulting from Transported Cargo If selecting this coverage option, please complete question 12 e. Business Interruption Expense Caused by Pollution Conditions f. Crisis Containment Expenses resulting from Pollution Conditions

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12. Coverage Option D - “Transported Cargo” Additional Questions a. Number of Licensed Motor Vehicles: b. Please attach your Motor Vehicle list c. Are hazardous materials transported? Yes No If Yes, please provide a description of such materials

d. Please provide a description of all cargo being transported:

Do you perform vehicle maintenance on site or is it provided by a third On-site Off-site e. party? Please describe:

f. Distance travelled: i. Owned / Leased: ii. Third Party:

CLAIMS INFORMATION

14. Has any application for Pollution Legal by the applicant, present owners, principals or partners ever been declined or Yes No coverage cancelled or non-renewed?

If Yes, please explain. Proposal Form p.6 of 10

15. Has the company during the last 5 years been prosecuted, or are you currently being prosecuted, or anticipate being named, inquired or Yes No prosecuted for any pollution, contamination or environmental incident?

If Yes, please explain:

16. Have any claims been made against the company during the last 5 years for clean up costs, property damage resulting from the release of Yes No pollutants or contaminants into the environment?

If Yes, please explain.

17. Has an Environmental Survey ever been completed? Yes No

If Yes, please provide a copy 18. Is there any known soil and or ground water contamination at any of your Yes No sites?

If Yes, please provide details

19. Does the company conduct any Environmental audits? Yes No

If Yes, please provide a copy

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20. Please provide a list of raw materials, products, by-products and wastes stored on site: Product Storage Method

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DECLARATION

(To be signed by a partner or director.)

I, the undersigned, declare and acknowledge:

- that I am, after enquiry, authorised by all person(s) or entities seeking insurance, to make this proposal; - that after enquiry, all information supplied in this proposal and any supporting documents attached to this proposal or supplied separately, is true and correct and I have not withheld any material information from this proposal - that this proposal and any accompanying documents shall form or partly form the basis of the contract proposed. - that until a Contract of Insurance is entered into, I am obliged to inform Liberty Specialty Markets of any changes to any information supplied or of any new information that is relevant; - that I understand Liberty Specialty Markets relies on the accuracy of the information and documentation supplied proposing for this insurance; - that I have read and understood the Important Notices which form part of this proposal; - that I understand that no insurance is in force until a Contract of Insurance is entered into, which is upon the Proposer’s acceptance of an offer by Liberty Specialty Markets, if any. - that the proposed Insured is a small business with a turnover of less than AU$2 million in the last financial year. Note that if No is selected or this question is left blank, in accordance with Ch 8, Pt 5A of the Duties Act 1997 (NSW), from 1 January 2018 Liberty will charge stamp duty on risks that 1) occur within or partly within NSW or 2) cover NSW property. Yes No

Signed

Print Name

Title

Dated

HAVE YOU REMEMBERED TO ATTACH THE FOLLOWING?

Environmental Audit Reports for each location requiring coverage (if available) Information on any previous environmental coverage and environmental loss experience Environmental site management plan Appendix A – Schedule of Covered Locations

Address Current Land Use Prior Land Use Surrounding Land Use Appendix B – Storage Tanks

21. Are tanks present at your site? Yes No

If Yes, please complete

Above or below Year installed Tank Capacity Tank Construction Contents of Tank Condition of Tank Type of leak detection